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Managing diabetes during ramadan

Proper planning to support patients who choose to fast in the Muslim holy month is crucial. Dr Mohammed Hassanein, Professor Anthony Barnett, Dr Devasenan Devendra and Ms Sunita Wallia offer practical guidance

Proper planning to support patients who choose to fast in the Muslim holy month is crucial. Dr Mohammed Hassanein, Professor Anthony Barnett, Dr Devasenan Devendra and Ms Sunita Wallia offer practical guidance

GPs who have Muslim patients with diabetes can help them fast safely and improve their diabetes management during Ramadan, which begins in mid-September.

Prolonged fasting may:
• deplete glycogen levels, increasing gluconeogenesis and ketogenesis
• pose a risk of hyperglycaemia
• increase the risk of ketoacidosis, especially in patients with type 1 diabetes.

Excessive reduction of drug doses may also increase the risk of hyperglycaemia and ketoacidosis.Fasting without accompanying changes to drug treatment may have important implications for safety while driving or at work. Furthermore, variations in blood glucose during Ramadan may increase HbA1C.

Reduced fluid intake during fasting may result in dehydration, leading to hyperglycaemic osmotic diuresis. Volume depletion may cause orthostatic hypotension, especially in individuals with autonomic neuropathy.

Diabetes is associated with a hypercoagulable state and the greater blood viscosity associated with dehydration increases the risk of thrombosis further.The scale of morbidity in the UK is probably masked by a lack of knowledge about fasting and its consequences among healthcare professionals, and a low level of awareness of the risks of fasting and symptoms among patients.

Standard medical advice for Muslims with diabetes is not to fast during Ramadan. This is permissible according to the Quran, but many patients still want to fast.

Patient and family education
The breaking of the Ramadan fast in the evening is a family occasion and everyone should understand its implications for the person with diabetes. Patients or their family may benefit from education on managing hypoglycaemic episodes – treating with rapidly acting carbohydrates such as three glucose tablets or 200ml of sugar-containing cola, followed by a sandwich, chapati or toast to prevent another episode. Emphasising the importance of consumption of starchy foods (rice, naan, chapati) and a diet with fruit, vegetables, dhal and yoghurt, rather than fatty and sugary food and drink, is also important in reducing complications.

Working with the community
Practice diabetes registers may not reliably identify Muslim patients at risk and contacting them by letter may not be effective. Management may be complicated by low literacy, conflict with cultural norms and a misplaced belief that health services offer treatment but not management advice.

Some patients may modify treatment without seeing a GP, while others may choose religious observance over medical advice, or take traditional medicines with hypoglycaemic properties. It is therefore essential to gain the support of Muslim community leaders in delivering messages about the risks associated with fasting so that patients consult their GPs.GPs can make contact with imams (clerics who may also be community leaders) directly, via senior members of the community or, if available, outreach workers or the community or specialist diabetes team.

It is a good idea to consult imams well before Ramadan, to ensure that advice to patients is consistent. Imams can also be asked to remind Muslims that people with diabetes are exempted from fasting and to encourage those who intend to fast to consult their GP or practice nurse.

Medical management
If patients insist on fasting, GPs can help minimise risks. The tailored management plan for Ramadan should include a review of the effectiveness of current treatment. Patients using insulin and/or sulphonylureas should understand the additional importance of regular blood glucose monitoring while fasting.

When fasting ends, patients should attend for a review to assess the effectiveness and safety of management during fasting and to optimise subsequent treatment. The individualised strategy for fasting during Ramadan should be incorporated into each patient's diabetes care plan and amended in light of the post-Ramadan review.

Further information
• Local mosques can be found at www.salaam.co.uk/mosques/searchmosques.php
• Diabetes UK (www.diabetes.org.uk) offers information in several languages
• Free consensus-based guidance on diabetes management during Ramadan is at care.diabetesjournals.org/cgi/ reprint/28/9/2305.

Anthony Barnett is professor of medicine and clinical director for diabetes and endocrinology at the University of Birmingham and Heart of England NHS Foundation Trust, Birmingham.
Dr Senan Devendra is community consultant diabetologist, Brent teaching PCT & Central Middlesex Hospital, London.
Sunita Wallia is community dietician in the Multicultural Health Programme in Glasgow.
Dr Devasenan Devendra is consultant physician at Central Middlesex Hospital

Competing interests The writing of the article was supported by an educational grant from Daiichi Sankyo, who had no influence on its content

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